Neighborhood attributes and cardiovascular disease risk in breast cancer survivors: The Pathways Study.

BACKGROUND: Breast cancer survivors are at a higher risk of cardiovascular disease (CVD) morbidity and mortality compared with the general population. The impact of objective social and built neighborhood attributes on CVD risk in a cohort of female breast cancer survivors was examined. METHODS: The 3975 participants came from the Pathways Study, a prospective cohort of women with invasive breast cancer from an integrated health care system in northern California. Women diagnosed with breast cancer from 2006 through 2013 were enrolled on average approximately 2 months after diagnosis. Their baseline addresses were geocoded and appended to neighborhood attributes for racial/ethnic composition, socioeconomic status (SES), population density, urbanization, crime, traffic density, street connectivity, parks, recreational facilities, and retail food environment. Incident CVD events included ischemic heart disease, heart failure, cardiomyopathy, or stroke. Cox proportional hazards models estimated associations of neighborhood attributes with CVD risk, which accounted for clustering by block groups. Fully adjusted models included sociodemographic, clinical, and behavioral factors. RESULTS: During follow-up through December 31, 2018, 340 participants (8.6%) had CVD events. A neighborhood racial/ethnic composition measure, percent of Asian American/Pacific Islander residents (lowest quintile hazard ratio [HR], 1.85; 95% CI, 1.03-3.33), and crime index (highest quartile HR, 1.48; 95% CI, 1.08-2.03) were associated with the risk of CVD events independent of individual SES, hormone receptor status, treatment, cardiometabolic comorbidities, body mass index, and physical activity. CONCLUSIONS: With the application of a socio-ecological framework, how residential environments shape health outcomes in women with breast cancer and affect CVD risk in this growing population can be understood.

Primary Care Providers and Nonalcoholic Fatty Liver Disease: A Needs Assessment Survey.

BACKGROUND: Primary care providers (PCPs) face increasing numbers of patients at risk for NAFLD and are responsible for the detection of NAFLD and the decision on referral to specialists. We conducted a PCP needs assessment to ascertain the barriers and desired supports for NAFLD in primary care. METHODS: We designed a cross-sectional study of PCPs at a large diverse health system and surveyed faculty, residents, and nurse practitioners. Questions assessed NAFLD knowledge, approach to diagnosis and fibrosis testing including use of FIB-4, and attitudes toward support tools. RESULTS: The survey was sent to 115 PCPs with an 80% (n = 92) response rate. Respondents were 52% faculty and 48% residents. Over 40% were unsure of which diagnostic tests to order and which data constituted a diagnosis. PCPs were aware of the importance of fibrosis, yet few knew the components of FIB-4, few used FIB-4 in practice, and yet the most common reason for referral was to obtain fibrosis staging. The majority showed high levels of interest toward possible tools to improve NAFLD management, and only 5% perceived lack of time to be a barrier. DISCUSSION: Our survey revealed PCPs need and want strategic approaches to NAFLD. We found PCPs lack confidence in diagnosing NAFLD and are inconsistent in management strategies. PCPs had high awareness of the importance of fibrosis, but not of the FIB-4. It was encouraging that PCPs reported that time was not a major barrier and had positive attitudes toward potential practice support tools, indicating that practice guidelines designed for primary care should be created.

Patient-reported supportive care needs among Asian American cancer patients.

PURPOSE: Cancer is the leading cause of death for Asian Americans. However, few studies have documented supportive care needs from the perspective of Asian American cancer patients. This study describes the needs reported by Asian American patients with colorectal, liver, or lung cancer over a 6-month period during their treatment. METHODS: Participants were recruited through the Greater Bay Area Cancer Registry and from cancer care providers in San Francisco. Participants self-identified as Asian or Asian American; were age 21 or older; spoke English, Chinese, or Vietnamese; and had stage I-III colon, rectum, liver, or lung cancer. Participants were matched with a language concordant patient navigator who provided support during a 6-month period. Needs were assessed by surveys at baseline, 3, and 6 months. RESULTS: Among 24 participants, 58% were 65 years or older, 42% did not complete high school, and 75% had limited English proficiency (LEP). At baseline, the most prevalent needs were cancer information (79%), nutrition and physical activity (67%), language assistance (54%), and daily living (50%). At the 3- and 6-month follow-up surveys, there was a higher reported need for mental health resources and healthcare access among participants. CONCLUSION: In this pilot study of Asian American cancer patients who predominantly had LEP, participants reported many needs, with cancer information and language assistance as the most prominent. The findings highlight the importance of culturally and linguistically appropriate patient navigators in addressing supportive care needs among cancer patients with LEP. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03867916.

Exploring factors associated with hepatitis B screening in a multilingual and diverse population.

BACKGROUND: Racial/ethnic minorities bear a disproportionate burden of hepatitis B virus (HBV) infection and disease. Disparities in HBV screening contribute to worse outcomes for communities of color. We examined the impact of race/ethnicity, language preference, and having a usual place of care on HBV screening in a multilingual, urban cohort. METHODS: We used questions from the Health Information National Trends Survey and added validated questions about healthcare access and health literacy. We administered this survey in English, Spanish, and Chinese to a selected convenience sample of San Francisco city/county residents in 2017, with pre-specified targets for populations with known cancer disparities: 25% Spanish-speaking, 25% Chinese-speaking, and 25% Black Americans. Using weighted multivariable logistic regression analyses, we assessed how race/ethnicity, language preference, and having a usual place of care impacts self-report of HBV screening. RESULTS: Overall, 1027 participants completed the survey (50% of surveys administered in English, 25% in Spanish, and 25% in Chinese). Only 50% of participants reported HBV screening. In multivariable analysis, Black (OR = 0.20, 95% CI 0.08-0.49), Latinx (OR = 0.33, 95% CI 0.13-0.85), Asian (OR = 0.31, 95% CI 0.10, 0.94), and 'Other' race/ethnicity (OR = 0.17, 95% CI 0.05-0.53) respondents had lower odds of HBV screening compared to non-Hispanic White respondents. Participants who had insurance had increased odds of HBV screening (OR = 2.70, 95% CI 1.48-4.93). CONCLUSIONS: HBV screening disparities persist for Black Americans, Asian Americans, Latinx, and the uninsured. Future studies should explore reasons why current strategies have not been implemented or are not successful, particularly in addressing racial/ethnic and insurance disparities.

Effect of a media intervention on hepatitis B screening among Vietnamese Americans.

Objective: There is a lack of controlled studies of community-wide interventions to increase screening for hepatitis B (HBV) among Asian Americans, particularly Vietnamese Americans, who disproportionately suffer from HBV-related illnesses. The objective of our study was to develop, implement, and evaluate the effectiveness of a media campaign to promote HBV screening among Vietnamese Americans.Design: We designed and implemented a three-year media campaign promoting HBV screening among Vietnamese Americans. Evaluation consisted of cross-sectional pre- and post-intervention population-based telephone surveys of Vietnamese Americans adults age 18-64 who spoke English or Vietnamese and lived in the Northern California (intervention) or Greater Washington, D.C. (comparison) communities in 2007 or 2011. Statistical analysis was completed in 2012. The main outcome was self-report of HBV testing, defined as participants answering 'Yes' to the question: 'Have you ever had a blood test to check for hepatitis B?'Results: The sample sizes at pre- and post-intervention were 1,704 and 1,666, respectively. Both communities reported increased exposure to HBV-related booklets, radio and television advertisements, and websites. Only the intervention community reported increased exposure to newspaper elements. HBV screening increased in both communities (intervention: 65.3% to 73.1%, p < 0.01, comparison: 57.7% to 66.0%, p < 0.01). In multivariable analyses, there was no intervention effect. In both communities, exposure to media elements (Odds Ratio 1.26 [95% Confidence Interval: 1.21, 1.31] for each additional element) was significantly associated with screening.Conclusions: Among Vietnamese Americans in 2 large communities, HBV screening rates were sub-optimal. Screening increased in both the intensive media intervention and comparison communities, and exposure to HBV-related media messages was associated with increased screening. Efforts to address HBV screening among Vietnamese Americans should include mass media messaging.

Death Toll of COVID-19 on Asian Americans: Disparities Revealed.

The coronavirus disease 2019 (COVID-19) pandemic has underscored the structural inequities facing communities of color and its consequences in lives lost. However, little is known about the COVID-related disparities facing Asian Americans amidst the heightened racism and violence against this community. We analyze the mortality toll of COVID-19 on Asian Americans using multiple measures. In 2020, one in seven Asian American deaths was attributable to COVID-19. We find that while Asian Americans make up a small proportion of COVID-19 deaths in the USA, they experience significantly higher excess all-cause mortality (3.1 times higher), case fatality rate (as high as 53% higher), and percentage of deaths attributed to COVID-19 (2.1 times higher) compared to non-Hispanic Whites. Mounting evidence suggest that disproportionately low testing rates, greater disease severity at care presentation, socioeconomic factors, and racial discrimination contribute to the observed disparities. Improving data reporting and uniformly confronting racism are key components to addressing health inequities facing communities of color.

Underrecognition and Suboptimal Quality of Care for Nonalcoholic Fatty Liver Disease Cirrhosis in Primary Care Patients with Diabetes Mellitus.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a leading cause of cirrhosis but is underrecognized in primary care. Cirrhosis management requires complex monitoring, and the quality of care (QoC) for NAFLD cirrhosis patients in primary care may be inadequate. METHODS: In this retrospective-prospective cohort study of primary care patients with diabetes mellitus, we identified patients with NAFLD cirrhosis by 1) evidence of cirrhosis from abdominal imaging identified by natural language processing, or 2) existence of International Classification of Diseases code for cirrhosis. A finding of either was followed by manual chart review for confirmation of both cirrhosis and NAFLD. We then determined if cirrhosis care measures were up-to-date, including hepatitis A and B vaccination, Model for End-Stage Liver Disease score components, esophagogastroduodenoscopy, and hepatocellular carcinoma screening. We created a composite score quantifying overall QoC (scale 0-8), with high QoC defined as ≥6 points. RESULTS: Among 3,028 primary care patients with diabetes mellitus, we identified 51 (1.7%) with NAFLD cirrhosis. Although 78% had ≥3 average primary care visits/year, only 24% completed hepatocellular carcinoma screening at least annually in at least 75% of years since diagnosis. The average QoC composite score was 4.9 (SD 2.4), and less than one-third had high QoC. CONCLUSIONS: NAFLD cirrhosis is prevalent but underdiagnosed in primary care, and receipt of comprehensive QoC was suboptimal. Given the rising incidence of NAFLD cirrhosis, primary care providers need improved awareness and mechanisms to ensure high QoC for this population.

Association between language discordance and unplanned hospital readmissions or emergency department revisits: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: Studies conflict about whether language discordance increases rates of hospital readmissions or emergency department (ED) revisits for adult and paediatric patients. The literature was systematically reviewed to investigate the association between language discordance and hospital readmission and ED revisit rates. DATA SOURCES: Searches were performed in PubMed, Embase and Google Scholar on 21 January 2021, and updated on 27 October 2022. No date or language limits were used. STUDY SELECTION: Articles that (1) were peer-reviewed publications; (2) contained data about patient or parental language skills and (3) included either unplanned hospital readmission or ED revisit as one of the outcomes, were screened for inclusion. Articles were excluded if: unavailable in English; contained no primary data or inaccessible in a full-text form (eg, abstract only). DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data using Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping reviews guidelines. We used the Newcastle-Ottawa Scale to assess data quality. Data were pooled using DerSimonian and Laird random-effects models. We performed a meta-analysis of 18 adult studies for 28-day or 30-day hospital readmission; 7 adult studies of 30-day ED revisits and 5 paediatric studies of 72-hour or 7-day ED revisits. We also conducted a stratified analysis by whether access to interpretation services was verified/provided for the adult readmission analysis. MAIN OUTCOMES AND MEASURES: Odds of hospital readmissions within a 28-day or 30-day period and ED revisits within a 7-day period. RESULTS: We generated 4830 citations from all data sources, of which 49 (12 paediatric; 36 adult; 1 with both adult and paediatric) were included. In our meta-analysis, language discordant adult patients had increased odds of hospital readmissions (OR 1.11, 95% CI 1.04 to 1.18). Among the 4 studies that verified interpretation services for language discordant patient-clinician interactions, there was no difference in readmission (OR 0.90, 95% CI 0.77 to 1.05), while studies that did not specify interpretation service access/use found higher odds of readmission (OR 1.14, 95% CI 1.06 to 1.22). Adult patients with a non-dominant language preference had higher odds of ED revisits (OR 1.07, 95% CI 1.004 to 1.152) compared with adults with a dominant language preference. In 5 paediatric studies, children of parents language discordant with providers had higher odds of ED revisits at 72 hours (OR 1.12, 95% CI 1.05 to 1.19) and 7 days (OR 1.02, 95% CI 1.01 to 1.03) compared with patients whose parents had language concordant communications. DISCUSSION: Adult patients with a non-dominant language preference have more hospital readmissions and ED revisits, and children with parents who have a non-dominant language preference have more ED revisits. Providing interpretation services may mitigate the impact of language discordance and reduce hospital readmissions among adult patients. PROSPERO REGISTRATION NUMBER: CRD42022302871.

Patient COUNTS: A pilot navigation program for Asian American cancer patients.

Many Asian American cancer patients face barriers to cancer care but little is known about their navigational needs. We designed and implemented a pilot study to provide culturally- and linguistically-appropriate navigation for Asian American cancer patients. We recruited Asian American adults age 21+ years, who spoke English, Cantonese, Mandarin, or Vietnamese, with newly diagnosed, stage I-III colorectal, liver, or lung cancer in the Northern California Bay Area. Participants were assigned a language-concordant patient navigator, who provided support and resources over 6 months. Surveys were administered at baseline, 3-, and 6-months to assess sociodemographic characteristics, healthcare access, quality of life (FACT-G), and cancer care needs. Participants' mean age was 65 years (range 38-81); 62% were men, 67% spoke Chinese, and 75% reported limited English proficiency. Forty-two percent of participants had lung, 38% colorectal, and 21% liver cancer. Of 24 participants who enrolled, 67% completed the program and 75% completed standard of care cancer treatment. The average total FACT-G score was 72.6 (SD 17) at baseline, 68.0 (SD 20) at 3 months, and 69.9 (SD 22) at 6 months. All participants reported that the program was culturally appropriate and would recommend it. Asian American cancer patients in a patient navigation program reported lower quality of life compared to the general adult cancer population. Even with navigation, 75% of participants reported completing standard of care treatment. While participants were satisfied with the program, more research is needed to address the quality of cancer care Asian American cancer patients receive.

Disparities in cancer stage shifts associated with the COVID-19 pandemic in California, 2020-2021.

BACKGROUND: The COVID-19 pandemic and associated shutdowns disrupted healthcare access and resulted in decreased cancer screenings. Cancer diagnosis delays have concerning downstream effects on late-stage cancer, especially for marginalized populations. METHODS: The study population included 349,458 adults in the California Cancer Registry diagnosed with cancer between January 2019-December 2021, during which California experienced two stay-at-home orders. We examined the percentage of late-stage (III-IV) cancer diagnoses across five periods: Pre-Pandemic (January 2019-February 2020), Shutdown #1 (March-June 2020), Post-Shutdown #1 (July-November 2020), Post-Shutdown #2 (December 2020-March 2021), and Post-Vaccine Rollout (April-December 2021). To examine the association between time-period and late-stage diagnoses, we conducted a multivariable log binomial regression model adjusted for sociodemographic and neighborhood factors. RESULTS: The percentage of late-stage cancer diagnoses increased during Shutdown #1 (+5.2%) and returned to baseline Post-Vaccine Rollout. Groups with notably higher increases in the percentage of late-stage cancer (vs. overall population) during Shutdown #1 include: Pacific Islander (+13.7%), Thai (+11.2%), Chinese (+8.1%), Native Hawaiian (+7.4%), Filipino (+6.6%), and uninsured (+7.4%). Uninsured (vs. private insurance) (PR: 1.41), low neighborhood SES (nSES) (vs. high) (PR: 1.19), and racial and ethnic minoritized groups (vs. NH White) (PR's: 1.04-1.19) had higher likelihood for late-stage cancer diagnosis. CONCLUSIONS: The pandemic exacerbated late-stage cancer disparities for racial and ethnic minoritized groups, underinsured, and low nSES communities in California (2020-2021). IMPACT: Interventions to improve cancer screening must be focused on racial and ethnic minoritized, underinsured, and low nSES communities, as they are likely to be more vulnerable to healthcare disruptions like the pandemic.

Correlates of supportive care needs among Asian Americans with colorectal, liver, or lung cancer from a web-based patient navigation portal intervention: The Patient COUNTS study.

BACKGROUND: Cancer is the leading cause of death among Asian Americans, who often face barriers to cancer care. Cancer supportive care needs among Asian Americans remain understudied. AIMS: We examined cancer supportive care needs and participant factors correlated with these needs, identified profiles of supportive care needs, and examined whether needs profiles are associated with quality of life among Asian American adults. METHODS AND RESULTS: We recruited 47 Asian American adults with colorectal, liver, or lung cancer who spoke Chinese, English, or Vietnamese, and were starting or undergoing cancer treatment. We assessed cancer supportive care needs in four domains: cancer information, daily living, behavioral health, and language assistance. Hierarchical cluster analysis was used to identify clusters of participants based on their supportive need profiles to further examine the association between need profiles and quality of life (QoL) assessed by the Functional Assessment of Cancer Therapy. Participants (mean age = 57.6) included 72% males and 62% spoke English less than very well. Older participants (age ≥ 65) and those with annual income <$50K reported higher daily living needs. Men and younger participants (age < 50) reported higher behavioral health needs. We found three clusters displaying distinct cancer supportive need profiles: Cluster 1 (28% of the sample) displayed high needs across all domains; Cluster 2 (51%) had low needs across all domains; and Cluster 3 (21%) had high needs for cancer information and daily living. Cluster 1 participants reported the lowest QoL. CONCLUSION: Cancer supportive care needs among Asian American patients with colorectal, liver, and lung cancer were associated with patient characteristics and QoL. Understanding cancer supportive care needs will inform future interventions to improve care and QoL for Asian American patients with cancer. CLINICALTRIALS: gov Identifier: NCT03867916.

Prospective study of a case-finding algorithm to detect NAFLD with advanced fibrosis in primary care patients.

BACKGROUND AND AIMS: Primary care providers need strategies to identify NAFLD patients and select for specialty referral, but proposed algorithms have only been studied in established NAFLD patients. METHODS: We implemented an algorithm for all adults with diabetes mellitus in a large primary care practice and excluded hepatitis B and C or alcohol use. Applying annual Fibrosis-4 Index and NAFLD Fibrosis Score for 5 years, we categorized patients as low-risk, indeterminate-risk, or high-risk for advanced fibrosis. We targeted all high-risk and messaged each primary care provider, recommending hepatology linkage. We collected final diagnosis and fibrosis (F0-4) outcomes. Using multivariable logistic regression, we assessed risk factors for advanced fibrosis stage (F3-4). RESULTS: Of 3028 patients, 1018 were low-risk, 577 indeterminate-risk, and 611 high-risk. There were 264 target patients; their 89 primary care providers received a message per patient suggesting hepatology referral. The majority (n=149) were referred; at triage, 118 were deemed likely NAFLD. Of these, 90 completed visits, 78/90 were diagnosed as NAFLD, and 69/78 underwent fibrosis staging, with F3 to 4 in 25/69. In multivariable analysis, hemoglobin A1c ≥8% (OR=7.02, 95% CI: 1.29-38.18) and Fibrosis-4 Index (OR=1.79, 95% CI: 1.07-2.99) were associated with increased risk of F3 to 4. CONCLUSIONS: This is the first prospective study testing a case-finding strategy in primary care and almost 1/3 of diabetes mellitus were high-risk for advanced fibrosis. When prompted, 73% of primary care providers placed referrals and 76% of patients completed visits, revealing 86% NAFLD and 36% F3 to 4. This study demonstrates the readiness for such a strategy in primary care; integrating hemoglobin A1c into this algorithm may further improve the performance of Fibrosis-4 Index in this setting.

The effectiveness and value of gene therapy for hemophilia: A Summary from the Institute for Clinical and Economic Review's California Technology Assessment Forum.

DISCLOSURES: Dr Tice and Mr Sarker received ICER grants during the conduct of the study. Dr Moradi, Ms Herce-Hagiwara, Dr Faghim, Dr Agboola, Dr Rind, and Dr Pearson reports grants from Arnold Ventures, grants from Blue Cross Blue Shield of MA, grants from California Healthcare Foundation, grants from The Commonwealth Fund, grants from The Peterson Center on Healthcare, during the conduct of the study; other from Aetna, other from America's Health Insurance Plans, other from Anthem, other from AbbVie, other from Alnylam, other from AstraZeneca, other from Biogen, other from Blue Shield of CA, other from Cambia Health Services, other from CVS, other from Editas, other from Express Scripts, other from Genentech/Roche, other from GlaxoSmithKline, other from Harvard Pilgrim, other from Health Care Service Corporation, other from Health Partners, other from Johnson & Johnson (Janssen), other from Kaiser Permanente, other from LEO Pharma, other from Mallinckrodt, other from Merck, other from Novartis, other from National Pharmaceutical Council, other from Premera, other from Prime Therapeutics, other from Regeneron, other from Sanofi, other from Spark Therapeutics, other from United Healthcare, other from HealthFirst, other from Pfizer, other from Boehringer-Ingelheim, other from uniQure, other from Evolve Pharmacy Solutions, other from Humana, other from Sun Life, outside the submitted work.

Increasing Telehealth Access to Care for Older Adults During the COVID-19 Pandemic at an Academic Medical Center: Video Visits for Elders Project (VVEP).

BACKGROUND: The COVID-19 pandemic led to a significant increase in ambulatory virtual care, threatening access to care for older adults with lower digital literacy. This report describes the Video Visits for Elders Project (VVEP), a quality improvement effort to help older adults access video visits at an academic primary care practice. METHODS: We reached out to empaneled older adults (≥ 65 years) who had a scheduled visit between March 30 and June 12, 2020. We assessed patients' readiness to engage in a virtual visit and offered to walk them through accessing the platform if they owned a compatible device. We evaluated outcomes of those phone calls and actual visit completion. RESULTS: Between March 26 and June 3, 2020, we called 1,427 patients, reaching 1,025 (71.8%). Of those reached (mean age 75.6 years), 312 (30.4%) were already video-enabled, 192 (18.7%) asked for technical assistance, 185 (18.0%) did not have access to an electronic device, and 336 (32.8%) declined assistance. Of those reached, 40.4% completed their visit by video, 26.5% by telephone, and 1.4% by in-person visit, while 29.6% canceled and 2.1% no-showed. CONCLUSION: VVEP successfully innovated to promote equitable access to telemedicine for vulnerable older patients in a time of crisis. Almost half required technical assistance or did not have access to a compatible device to engage in virtual care. As telemedicine will continue to play an important role in access to clinical care even in a postpandemic world, it is imperative for health systems to focus on technological need to promote equitable access to care for all patients.

Impact of language preference and health literacy on health information-seeking experiences among a low-income, multilingual cohort.

OBJECTIVE: We examined the impact of language preference and health literacy on health information-seeking experiences in a multilingual, low-income cohort. METHODS: We administered a modified Health Information National Trends Survey in English, Spanish, and Chinese to a sample of San Francisco city/county residents. Using multivariable logistic regression analyses, we assessed how language and health literacy impact health information-seeking experiences (confidence, effort, frustration, quality concerns, and difficulty understanding information), adjusting for age, gender, race/ethnicity, education, usual place of care, health status, information-seeking behaviors, and smartphone ownership. RESULTS: Of 1000 participants (487 English-speaking, 256 Spanish-speaking, 257 Chinese-speaking), 820 (82%) reported at least one negative health information-seeking experience. Chinese-language was associated with frustration (aOR = 2.56; 1.12-5.86). Difficulty understanding information was more likely in Spanish-language respondents (aOR = 3.58; 1.25-10.24). Participants with limited health literacy reported more effort (aOR = 1.97; 1.22-3.17), frustration (aOR = 2.09; 1.28-3.43), concern about quality (aOR = 2.72; 1.60-4.61), and difficulty understanding information (aOR = 2.53; 1.58-4.05). Language and literacy impacted confidence only in the interaction term between Chinese-speakers and health literacy. CONCLUSION: We found that negative health information-seeking experiences were common in non-English speaking populations those with limited health literacy. PRACTICE IMPLICATIONS: Health communication efforts should consider both language preference and health literacy to ensure accessibility for all patients.

Racial/ethnic differences in fibrosis prevalence and progression in biopsy-proven steatosis: A focus on the Asian American population.

Fatty liver disease (FLD) is a leading cause of chronic liver disease (CLD) globally, and vulnerable populations are disproportionately affected. Prior studies have suggested racial/ethnic differences in FLD prevalence and severity; however, these studies often excluded Asian Americans. This study aims to evaluate racial/ethnic differences in the prevalence of, and predictors associated with steatohepatitis, advanced fibrosis, and fibrosis progression over time within a diverse population. Using descriptive analyses and multivariable modeling, we performed a longitudinal evaluation of 648 patients with histologic evidence of FLD (steatosis or steatohepatitis) from August 2009 to February 2020 within San Francisco's safety-net health care system. Overall demographics were median age of 53 years, 54% male, and 38% Asian (40% Hispanic, 14% White). On histology, 61% had steatohepatitis and 30% had advanced fibrosis (≥F3). The comparison between steatosis and steatohepatitis groups showed differences in sex, race/ethnicity, metabolic risk factors, and co-existing CLD (predominantly viral hepatitis); patients with steatosis were more likely to be Asian (50%), and those with steatohepatitis were more likely to be Hispanic (51%). On multivariable modeling, while Asian race (vs. non-Asian) was not associated with steatohepatitis or advanced fibrosis when models included all relevant clinical predictors, Asian race was associated with higher relative risk of fibrosis progression as defined by change in Fibrosis-4 category over time (relative risk ratio = 1.9; p = 0.047). Conclusion: In this vulnerable population with a large proportion of Asian Americans, Asian race was associated with progression of fibrosis. Given the relative paucity of data in this high-risk group, future studies should confirm these findings.

Asian American/Pacific Islander and Hispanic Ethnic Enclaves, Neighborhood Socioeconomic Status, and Hepatocellular Carcinoma Incidence in California: An Update.

BACKGROUND: Using more recent cancer registry data, we analyzed disparities in hepatocellular carcinoma (HCC) incidence by ethnic enclave and neighborhood socioeconomic status (nSES) among Asian American/Pacific Islander (AAPI) and Hispanic populations in California. METHODS: Primary, invasive HCC cases were identified from the California Cancer Registry during 1988-1992, 1998-2002, and 2008-2012. Age-adjusted incidence rates (per 100,000 population), incidence rate ratios, and corresponding 95% confidence intervals were calculated for AAPI or Hispanic enclave, nSES, and the joint effects of ethnic enclave and nSES by time period (and the combination of the three periods), sex, and race/ethnicity. RESULTS: In the combined time period, HCC risk increased 25% for highest versus lowest quintile of AAPI enclave among AAPI males. HCC risk increased 22% and 56% for lowest versus highest quintile of nSES among AAPI females and males, respectively. In joint analysis, AAPI males living in low nSES areas irrespective of enclave status were at 17% to 43% increased HCC risk compared with AAPI males living in areas of nonenclave/high nSES. HCC risk increased by 22% for Hispanic females living in areas of low nSES irrespective of enclave status and by 19% for Hispanic males living in areas of nonenclave/low nSES compared with their counterparts living in areas of nonenclave/high nSES. CONCLUSIONS: We found significant variation in HCC incidence by ethnic enclave and nSES among AAPI and Hispanic populations in California by sex and time period. IMPACT: Future studies should explore how specific attributes of enclaves and nSES impact HCC risk for AAPI and Hispanic populations.

Evaluating the Impact of Social and Built Environments on Health-Related Quality of Life among Cancer Survivors.

BACKGROUND: With almost 17 million U.S. cancer survivors, understanding multilevel factors impacting health-related quality of life (HRQOL) is critical to improving survivorship outcomes. Few studies have evaluated neighborhood impact on HRQOL among cancer survivors. METHODS: We combined sociodemographic, clinical, and behavioral data from three registry-based studies in California. Using a three-level mixed linear regression model (participants nested within block groups and study/regions), we examined associations of both independent neighborhood attributes and neighborhood archetypes, which capture interactions inherent among neighborhood attributes, with two HRQOL outcomes, physical (PCS) and mental (MCS) composite scores. RESULTS: For the 2,477 survivors, 46% were 70+ years, 52% were non-Hispanic White, and 53% had localized disease. In models minimally adjusted for age, stage, and cancer recurrence, HRQOL was associated with neighborhood socioeconomic status (nSES), racial/ethnic composition, population density, street connectivity, restaurant environment index, traffic density, urbanicity, crowding, rental properties, and non-single family units. In fully adjusted models, higher nSES remained associated with better PCS, and restaurant environment index, specifically more unhealthy restaurants, associated with worse MCS. In multivariable-adjusted models of neighborhood archetype, compared with upper middle-class suburb, Hispanic small town and inner city had lower PCS, and high status had higher MCS. CONCLUSIONS: Among survivors, higher nSES was associated with better HRQOL; more unhealthy restaurants were associated with worse HQROL. As some neighborhood archetypes were associated with HRQOL, they provide an approach to capture how neighborhood attributes interact to impact HRQOL. IMPACT: Elucidating the pathways through which neighborhood attributes influence HRQOL is important in improving survivorship outcomes.